Empyema After Pneumonectomy

Transcription

1 George L. Zumbro, Jr., Maj, Robert Treasure, Col, James P. Geiger, M.D., Col (Ret), and David C. Green, Col, all MC, USA ABSTRACT Ten patients who developed empyema after pneumonectomy are discussed. The bacteriological spectrum and possible etiological features are reviewed. The various methods of management are discussed, and Clagett s twostage method is recommended, even if a bronchopleural fistula is initially present. Selection of the appropriate antibiotic solution for instillation into the pleural cavity is also discussed. S ince the introduction of antibiotics and modern surgical techniques, infection of the pleural space following pneumonectomy has become an infrequent occurrence. Due to the rarity of this complication, no single surgeon gains a great amount of experience in its management. Modern surgical management of empyema after pneumonectomy is controversial, with opinion divided between thoracoplasty and various modifications of the operation described by Clagett [I, 2, 5, 6, 81. Moreover, with the added presence of a bronchopleural fistula opinion is further divided, with some surgeons advocating early reoperation and closure of the bronchopleural fistula [3]. With the exception of a recent American report and two European articles, a review of the literature fails to reveal more than sporadic case reports dealing with this problem over the past twenty years [3, 8, 91. Clinical Material From 1957 to 1970, 10 cases of postpneumonectomy empyema were recorded at Walter Reed General Hospital (WRGH). Nine patients had undergone pneumonectomy for bronchogenic carcinoma at WRGH, and 1 patient had had a left pneumonectomy because of gunshot wounds of the left lung sustained in Vietnam. Two possible etiological factors were contamination of the pleural space and the administration of radiation therapy either preoperatively or postoperatively. Five of the 9 patients undergoing pneumonectomy for carcinoma of the lung received radiation therapy (Table). As expected, the patient with From the Thoracic Surgery Service, Walter Reed General Hospital, Washington, D.C. Presented at the Ninth Annual Meeting of The Society of Thoracic Surgeons, Houston, Tex., Jan , Address reprint requests to Maj Zumbro, Thoracic Surgery Service, Erooke General Hospital, San Antonio, Tex VOL. 15, NO. 6, JUNE,

2 T Q, ETIOLOGICAL FACTORS AND MANAGEMENT OF EMPYEMA AFTER PNEUMONECTOMY IN 10 PATIENTS * Time from 3 Pneumonectomy Bronchob to Empyema Radiation pleural Organism z Patient Diagnosis Therapy Fistula Cultured Management of Empyema v) $ 1 8 days None No Staphylococcus Tube thoracostomy; died 3 wk. postop., aureus cardiac arrhythmia $ 2 14 days 4,200 R YeS S. aureus Open drainage-bronchopleural fistula closed; postop. died 3 yr. postop., recurrent tumor 7a $ 3 14 days 5,800 R YeS S. aureus Open drainage followed by thoracoplasty; * preop. died 3 yr. postop., recurrent tumor; draining a n sinus still present from pleural space v, 4 12 days None Yes Pseudom onas Open drainage followed by Clagett closure; ga C aeruginosa 1 yr. after closure alive and well f days None Yes S. aureus Open drainage followed by Clagett closure; z died 2 yr. postop., recurrent tumor; at postmortem pleural space sterile 6 22 days 5,000 R Yes S. aureus Open drainage; died 7 mo. postop., recurrent preop. tumor 7 5 mo. 4,200 R Yes S. aureus; Open drainage; died 9 mo. postop., recurrent postop. Escherichia coli tumor 8 2 mo. 5,000 R No S. aureus Open drainage followed by thoracoplasty ; died postop. 2 yr. postop., recurrent tumor; draining sinus 9 2 sinus from pleural space Open drainage followed by thoracoplasty; died 1 $L2 yr. postop., recurrent tumor with draining present from pleural space mo. None No S. aureus lo" 14 days None Yes E. coli; Open drainage followed by Clagett closure; Proteus alive and well 3 yr. postop. mira b ilis "Gunshot wound in left chest.

3 the gunshot wound of the left chest had contamination of the pleural space, which might have contributed to the development of an empyema. Three patients developed an early wound infection that might have contributed to the development of an infected pleural space. Initial cultures of the pleural fluid were positive in all 10 patients. Single organisms were cultured in 8 patients, and more than one organism was cultured in 2 patients (see Table). Staphylococcus aureus was grown out in 7 patients having a single organism cultured and also in 1 patient with a mixed infection. Seven of the 10 patients developed a bronchopleural fistula in association with the empyema. None of these fistulas were judged to be massive, and none caused respiratory distress. All 7 bronchopleural fistulas closed after institution of open drainage of the empyema cavity. Only 1 patient demonstrated residual tumor in the bronchial stump, and this was 1 of the 3 patients who did not develop a bronchopleural fistula. Four of the 5 patients who received irradiation developed a bronchopleural fistula. The period of time from pneumonectomy to the development of an empyema ranged from eight days to five months; however, the most frequent time of occurrence was from ten to fourteen days postoperatively. Four patients had a temperature greater than 101 F. and signs of systemic toxicity. Expectoration of pleural fluid was seen in 3 patients. (Purulent drainage to the incision-empyema necessitatis-occurred in 4 patients.) Three patients demonstrated an air-fluid level on the chest roentgenogram as an initial diagnostic feature. Management Four different methods of management were used, depending on the time period in this study, the patient s general condition, and acceptance of the surgeon s recommendations (see Table). Since 1968, 3 patients have been managed by Clagett s two-stage method, consisting first of creating an open chest window for six to eight weeks irrigation of the empyema cavity followed by closure of the open window after instillation of an antibiotic solution. Two patients managed in this fashion are alive and well one year and three years later, respectively. One patient died two years postoperatively of recurrent tumor, and at postmortem examination there was no evidence of infection in the pleural space. The remaining patients were managed prior to the adoption of Clagett s method at WRGH in 1968 (see Table). Three patients underwent open drainage followed by extensive extrapleural thoracoplasty with removal of the second through ninth ribs and the corresponding transverse processes. All 3 patients subsequently died of recurrent tumor. Moreover, all 3 patients had residual draining sinuses from the pleural space at the time of death, indicating failure of the thoracoplasty to obliterate the empyema cavity. VOL. 15, NO. 6, JUNE,

4 ZUMBRO ET AL. An additional 3 patients underwent open chest-wall window drainage but died of metastatic tumor before definitive surgical therapy could be performed. One patient had closed tube thoracostomy performed but died of a cardiac arrhythmia three weeks postoperatively, before further management of the empyema could be accomplished. Mortality No patients died directly as a result of infection of the pleural space. One patient died of myocardial infarction and a fatal ventricular arrhythmia three weeks after pneumonectomy. Seven patients died ten months to thirtyseven months postoperatively from recurrent tumor, for an overall mortality of 8 out of 10 patients. Comment While it is difficult to determine the exact etiology of postpneumonectomy empyema, radiation therapy in 5 of the patients did seem to be a contributing factor. All patients received radiation therapy in sufficient dosages and temporal relationships (three to ninety days before development of empyema) for it to have been an etiological factor in the development of this complication. Contamination of the pleural space, either intraoperatively or postoperatively by infection of the incision, could account for postpneumonectomy empyema. Intraoperative contamination was seen in 1 patient (gunshot wound), and postoperative contamination of the pleural space by wound infection was seen in an additional 3 patients. The clinical signs of infection of the pleural space after pneumonectomy vary widely and, as demonstrated here, may not appear for several months after operation. Therefore, the possibility of empyema should be considered in any patient with signs of infection following pneumonectomy, no matter how far in the past the patient underwent the procedure. Certainly unexplained fever, expectoration of serosanguineous fluid, purulent drainage in the wound, or an air-fluid level seen on the chest roentgenogram should immediately arouse suspicion of an infected pleural space and a bronchopleural fistula. Dahlback and Schuller [3] advocated early reoperation and closure of the bronchial stump in the presence of a bronchopleural fistula; however, the mortality rate was greater than 30 %. Virkhula and Kostiainen [9] have advocated initial management by open-window thoracostomy in all patients, whether or not a bronchopleural fistula was present, and later closure by the Clagett method when the bronchopleural fistula had closed. Our experience suggests that with open-window drainage most small- to moderate-sized bronchopleural fistulas will thus close, allowing further management by the Clagett method. It is significant that none of our patients died as a result of 618 THE ANNALS OF THORACIC SURGERY

5 empyema or the surgical procedures performed for it, indicating the adequacy of initial drainage of the septic process by the open-window technique. The inadequacy of thoracoplasty to obliterate the infected pleural space was demonstrated by the persistent draining sinuses present at the time of death in all 3 patients having thoracoplasty as the definitive procedure. We are convinced that the proper initial approach to postpneumonectomy empyema is open-window thoracostomy to drain the infected pleural space and to relieve signs of systemic toxicity. The initial approach is the same, whether or not a bronchopleural fistula is present. One can then decide at a later date whether closure of the empyema cavity is feasible, depending upon the patient s general condition and the presence or absence of a bronchopleural fistula. In our experience, the bronchopleural fistula is apt to close and allow final closure and instillation of an antibiotic solution. Closure by the Clagett method involves little operative trauma and is tolerated by the majority of patients regardless of age and the presence of residual tumor. The choice of an antibiotic solution for instillation into the pleural space has been a subject of debate. Clagett s original solution contained neomycin; however, Samson [7] recommends a solution containing neomycin, bacitracin, and colistimethate. It seems reasonable that one should select the appropriate antibiotic based on the organism cultured and its in vitro sensitivity, since the renal and otic complications of the aforementioned antibiotics are well known [4]. In view of the report by Myerson and colleagues [4] on ototoxicity after irrigation of the pleural space with 1% neomycin followed by instillation of the same solution and closure of the chest wall, it is not advisable to use the same antibiotic solution for preoperative irrigation and final instillation prior to closure if the chosen antibiotic carries a potential risk of nephrotoxicity or ototoxicity. In spite of the known complications mentioned above, no data are available concerning antibiotic blood levels after instillation into the pleural space. In an effort to gain some knowledge about the absorption of the antibiotic solution from the pleural space after closure by Clagett s method, we measured gentamicin blood levels in our most recent patient managed by this method. Gentamicin, 100 mg., was placed in 150 ml. of saline and instilled into the empyema cavity prior to closure. The gentamicin blood levels over a sixteen-hour period were comparable to those obtained by a similar dose injected intramuscularly. References 1. Clagett, 0. T., and Geraci, J. E. A procedure for the management of postpneumonectomy empyema. J. Thorac. Cardiovasc. Surg. 45: 141, Conklin, W. S. Post-pneumonectomy empyema: Single-stage operative treatment. J. Thorac. Cardiovasc. Surg. 55~634, VOL. 15, NO. 6, JUNE,

6 ZUMBRO ET AL. 3. Dahlback, V. O., and Schuller, H. Die operative Behandlung der Bronchusstumpfinsuffizienz nach Pneumonektomie. Thoraxchirurgie 13:216, Myerson, M., Knight, H. F., Gambarini, A. J., and Curran, T. L. Intrapleural neomycin causing ototoxicity. Ann. Thorac. Surg. 9:483, Provan, J. L. The management of post-pneumonectomy empyema. J. Thorac. Cardiovasc. Surg. 61:107, Robinson, C. L. N. Pyogenic post-pneumonectomy empyema. Can. Med. Assoc. J. 95: 1294, Samson, P. C. Empyema thoracis: Essentials of present-day management. Ann. Thorac. Surg. 11:210, Stafford, E. G., and Clagett, 0. T. Post-pneumonectomy empyema: Neomycin instillation and definitive closure. J. Thorac. Cardiovasc. Surg. 63:771, Virkhula, L., and Kostiainen, S. Post-pneumonectomy empyema in pulmonary carcinoma patients. Scand. J. Thorac. Cardiovasc. Surg. 4:267, Discussion DR. PAUL C. SAMSON (Oakland, Calif.): Over the years, unfortunately, we have had some experience with postpneumonectomy empyema. There are many ways to skin this cat, but I agree with the authors that the surest way is some modification of the Clagett procedure, always providing that no bronchopleural fistula is evident. Our technique is very similar to the authors, with some minor modifications, and has been used successfully in 9 out of the last 10 empyemas we have encountered. Historically, a total thoracoplasty used to be necessary to close an empyema. I think one of the reasons the authors have had trouble with their thoracoplasties is that one should resect ribs 1 through 11 rather than leaving the first rib in as the authors suggested. By this means you can sometimes close the complete empyema space. We treated 1 patient with empyema by means of total thoracoplasty closure in a carcinoma, and the patient is still alive thirteen years later. In 1 patient whose thoracoplasty was unsuccessful at the time of Clagett s original article, we closed the space by neomycin instillation. This was some ten years ago, and the patient is still. doing well. We construct a large, open flap drainage quite similar to the authors except that it is a little larger, and we pack the space rather than irrigating it. In patients with carcinoma we like to pack the space for nearly a year to be sure that we don t have recurrence. Following closure we use a broad-coverage antibiotic solution with neomycin (250 mg. per 100 ml.), bacitracin (25,000 U. per 100 ml.), and Coly-Mycin (150 mg. per 100 ml.) for additional coverage against Staphylococcus and Pseudomonas. I have not used gentamicin. I would like to call the authors attention to Adler s recent article (Surgery 71:210, 1972) with some statistics on neomycin serum assay following instillation. Because bronchopleural fistulas sometimes cause difficulty, a method of successful closure is important. This can be done some weeks following open flap drainage. Through a paraspinal incision ribs 4 and 5 are resected to release a posterior pedicle intercostal muscle flap. The bronchial fistula is mobilized by dissecting the surrounding peel and entering the extrapleural plane. The fistula is closed in two layers. Further dissection of the peel posteriorly creates a trough in which the intercostal pedicle is laid, covering the bronchial fistula. The overlying pedicle is sutured in place. The edges of the peel are then pulled further over the intercostal pedicle to protect it. Within four to six weeks this type of repair will be covered by firm fibroblastic tissue and fresh granulations. A Clagett type of empyema obliteration can then be undertaken successfully. 620 THE ANNALS OF THORACIC SURGERY

7 DR. ANDR~ P. NAEF (Yverdon, Switzerland): One special problem is certainly the total, wide bronchial fistula, as Dr. Samson has just shown. At the 1971 meeting of the American Association for Thoracic Surgery we showed that even a chronic empyema due to Escherichia coli, Staphylococcus, or Pseudomonas will heal if the wide-open bronchial stump is successfully closed by reoperation. Even a space-reducing thoracoplasty is not necessary. We have treated 1 patient with empyema on the right side of five months' duration and 2 patients with empyema on the left side of eight months' duration. Following reoperation the empyemas healed, and all 3 patients have been cured for three to six years now. The difficulty is the correct reamputation flush with the carina on the left side. It is necessary to mobilize the whole tracheobronchial bifurcation to really perform a satisfactory suture at the carina. Once the bronchus is securely closed, the empyema will heal in a matter of weeks with the correct antibiotic therapy and will not recur. DR. WALTER L. BARKER (Chicago, Ill.): From 1954 to 1971 at the former Chicago State Tuberculosis Sanitarium we had experience with more than 290 pneumonectomies in a predominantly tuberculous population. Twenty-eight empyemas were encountered, 21 without and 7 with bronchopleural fistula. Our management was similar in outline to that of the authors. Drainage alone was used in 6 patients. In only 1 instance did this suffice. The remaining 5 patients died, having been too infected to undergo any more definitive procedures. Prior to 1964 all such complications ordinarily were handled with drainage and extensive thoracoplasty as demonstrated by Dr. Samson. Eleven of these patients did well, with obliteration of the empyema space and permanent closure of any fistulas. In 2 patients, despite revision of their thoracoplasty, associated fistulas failed to close. Both died many months later from chronic pyogenic nontuberculous suppuration. After 1964, 11 such patients were treated with the Clagett two-stage procedure approximately as described by the authors and with a similar bacterial spectrum and antibiotic coverage. Nine patients were successfully managed in this manner. Two failures were encountered, both in association with probable active pleural tuberculosis. In 1 of these patients a previously closed bronchopleural fistula reopened, necessitating drainage and thoracoplasty. In general we, too, favor and endorse the nonmutilating Clagett procedure for management of postpneumonectomy empyema in patients with no evidence or only a transient appearance of bronchopleural fistula. However, for patients who have persistent fistula or uncontrolled pleural contamination with pulmonary tuberculosis, drainage and thoracoplasty-and even eventual pedicle muscle grafting-may be the only surgical recourse. DR. ZUMBRO: Our failure to resect the first rib may be a reflection of the young thoracic surgeons involved and the lack of experience with thoracoplasty techniques. I include myself. Dr. Naef, we have no experience with reoperation and closure of bronchopleural fistula. I did not understand exactly at what point you reoperate. I do know that there is another report in the European literature in which this was done with a mortality of approximately 30%. For this reason we have steered away from trying to resuture the bronchial stump. VOL. 15, NO. 6, JUNE,